Understanding maternal Ethnomedical Folklore in Central Uganda: a cross-sectional study of herbal remedies for managing Postpartum hemorrhage, inducing uterine contractions and abortion in Najjembe sub-county, Buikwe district

Abstract Pregnant women in rural Uganda largely rely on medicinal plants for inducing labor, treating postpartum hemorrhage (PPH), and inducing abortion. 90% of the women in both rural and urban Uganda use plants to manage pregnancy symptoms like constipation, heartburn, morning sickness, body aches, nausea, and vomiting. After delivery women continue using plants to manage postpartum complications and for infant care especially herbal baths. This study documented how ethnomedical folklore has been used to aid childbirth, manage postpartum hemorrhage, and induce abortion. Methods A cross-sectional ethnobotanical survey was conducted from May – December 2023 in Najjemebe sub-county, Buikwe district. 206 respondents from 12 villages were selected using snowball sampling. Key informants included Traditional Birth Attendants (TBAs) and herbalists. Data was collected using semi-structured questionnaires and focus group discussions. Voucher specimens of the plants were identified and authenticated at Makerere University Herbarium. Data were analyzed using descriptive statistics, Informant Consensus factor (ICF), Use Reports (URs), paired comparisons, and GraphPad Prism® version 9.0.0 software. Results All respondents (N = 206, 100%), used plants to induce labour, treat PPH, and induce abortion. One hundred four plant species were documented: most cited or preferred were: Hoslundia opposita (N = 109, 53%), Phytolacca dodecandra (N = 72, 35%), and Commelina erecta (N = 47, 23%). The plants belonged to 49 families, Lamiaceae (16.3%) and Fabaceae (14.3%) having the majority of the species. Herbs were 42 (40%) and trees 23 (22%). Oral administration 95(72%) was the commonest, then topical 19 (14.4%) and vaginal 14(10.6%). Conclusion Health surveys revealed that about 27% of deliveries in Uganda take place outside a health facility. Due to the oxytocic effects of plant species reported in this study, they play a triple role of being uterotonics, abortifacients, and treating postpartum haemmorhage. The dilemma lies in the unknown dosages and toxicity levels that could endanger both the mother’s and the unborn child’s lives. Due to Uganda’s high rates of population growth, overall fertility, maternal mortality, and morbidity, policies, and programmes on gendered health provision need to be reevaluated. Integrating herbal medicine into health care systems appears to be a feasible solution. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-024-03205-w.


Introduction
Historically, women have relied on the health benefits of herbal medicine for pregnancies, deliveries, and postpartum care.Like other impoverished countries with sizable populations, Uganda is essentially unable to meet the basic healthcare demands of its female citizens.Thus, maternal mortality and morbidity, represent the most pressing issue [1].Furthermore, in Uganda, postpartum hemorrhage (PPH) accounts for 25% of all maternal deaths [2], and the majority of deaths due to PPH occur at traditional birth attendants (TBAs).Additionally, unsafe abortion mainly practiced among adolescents and women battling domestic violence also contributes significantly to the high maternal mortality rate.Unsafe abortion in low-income countries accounts for 13% of all maternal deaths [3].
Coupled with the high fertility of Ugandan women, the maternal mortality rate is 336 deaths per 100,000 live births, one of the highest in sub-Saharan Africa [4].Although most women receive antenatal care (91%), trained healthcare workers [5], supervise only 37% [6].In rural western Uganda, close to 80% of pregnant women deliver at home [6] with the aid of herbal medicine to induce labour, tone uterus muscles, remove the retained placenta, and manage post-partum bleeding [7].
In addition to the well-established indigenous healthcare system, the widespread use of traditional medicine (TM) in rural Uganda stems from several factors, including sociocultural acceptance of TM, the stigma associated with visiting healthcare facilities because of harsh and rude midwives, the fear of finding out one's HIV/AIDS status.Despite the pros, there is a wide gap between the continued use of indigenous knowledge of plants in the maternal healthcare and scientific validation of the species being used.Furthermore, not much has been documented in regards to these plant species leading to the loss of this knowledge through cultural erosion and death of custodians.Thus, this study was undertaken to record the indigenous knowledge regarding maternal health to preserve it for the future generation notwithstanding promoting the conservation of the important medicinal plant species.This will act as a lead for the discovery of new drugs.

Methods
An ethnobotanical survey was carried out in the Najjembe sub-county, Buikwe district (0°20'36.0"N,33°01'44.0"E), Central Uganda, home to Mabira Central Forest Reserve (Fig. 1) the second largest natural forest in Uganda.Mabira forest is a source of many medicinal plant species and greatly contributes to the livelihoods and survival of the surrounding population.Buikwe District is bordered by Kayunga District to the north, Jinja District to the east, Buvuma District to the southeast, the Republic of Tanzania to the south, and Mukono District to the west.Najjembe sub-county has 8,165 households and houses a population of 33,410 people of which 50.3% are male [4].In Buikwe district, the vast majority of inhabitants (66.5%) reside in rural areas [4].Implying more than half of the population are rural dwellers.The district's economic activities include sugarcane growing and subsistence farming.Eight sub-counties, Nyenga, Najjembe, Ssi Bukunja, Najja, Ngogwe, Buikwe, Kawolo, and Wakisi, as well as two town councils, Njeru and Lugazi, make up the district [8].Due to the tropical rainforest climate, there are no distinct seasons in the year.In addition to a greater dependence on traditional birth attendants, the Mabira forest reserve's abundance of medicinal plants has enhanced the women's indigenous health care system.Consequently, there is a greater dependence on medicinal plants to induce uterine contractions, tonify the uterus, induce abortion, and manage postpartum haemorrhage.Najjembe sub-county served as the study's location (Fig. 1).

Sample size and sampling procedures
Using the table by Krejcie and Morgan [9] a sample size of 206 respondents was computed based on a population of 440.Four parishes namely; Buvunya, Kabanga, Kizigo, and Nsakya were randomly sampled from which 12 villages (Buvunya, Buwundo, Kabanga, Bugoya, Kizigo, Bukolongo, Ddangala, Kasokoso, Mubango, Nsakya A, Nsakya B, Ssese) were purposively sampled taking into account the adult population.Male and female responders who were at least 18 years old were included in this group.

Study design, selection of study sites, and participants
All study participants were asked to sign an informed consent form before participation in the study.All methods were carried out following relevant guidelines and regulations as per the School of Health Sciences Ethical Review Board, Makerere University.The field survey was conducted from May -December 2023 using a crosssectional study design.Seven parishes namely Nsakya, Kabanga, Kinoni, Buwoola, Kitigoma, Kizigo, and Buvunya were randomly selected in Najjembe sub-county and eventually, villages were considered from each parish depending on the population size of the parish, giving a total of 12 villages.Inclusion criteria of study participants: Mothers aged 18 and above, Herbalists both men and women, Traditional Birth Attendants these are usually elderly women, then men who always go and collect herbs for their wives and are knowledgeable about traditional medicine (TM).Exclusion Criteria: All minors, mothers who do not use plants as medicine for their reproductive health, and women or men who are ignorant about TM.Using snowball sampling, women and men aged 18 and above who had experience in indigenous knowledge of plants used for maternal health were selected.As for key informants, traditional birth attendants and herbalists were identified using the snowballing method based on the principle of saturation [10].Once a TBA was identified and interviewed, they were asked to refer the research team to another TBA within their networks.The subsequent TBA then referred us to the next TBA in their networks until saturation was reached.The same procedure was followed when choosing herbalists to participate in the study.From each village, 10-15 respondents were interviewed altogether.All respondents first signed consent forms before participating in the study and each respondent was compensated for the time spent participating in the study.

Ethnobotanical data collection
Ethnobotanical data collection lasted seven months from May -December 2023.Before data collection, a pilot study which lasted one month was undertaken in May 2023 to introduce the study to the local area administration, seek their permission to conduct the study, and pretest the study tool.Information from the pilot helped in the modification of the final study.Data were collected using a semi-structured questionnaire (Supplementary file 1).All questions that were included in the questionnaire revolved around indigenous knowledge of plants used for maternal health specific to the treatment of postpartum bleeding, inducing uterine contractions, and abortions.Special emphasis was put on the time during and after pregnancy when such botanical remedies were administered.Other nonplant materials that were used for the same cause were also recorded.Six focus group discussions were held with community members to verify the information recorded in the individual interviews.Pairwise ranking was done to get the species that were considered most efficacious by TBAs, mothers, and herbalists.Voucher specimens of the plant species used were collected and taken to the Makerere University Herbarium for identification.Species nomenclature followed the fora for tropical East Africa and was verified using the Plants of the World Online (POWO) database (https:// powo.science.kew.org).

Data analysis
The data were entered into Microsoft Excel, coded, and exported to SPSS software (version 26, SPSS Inc.) for analysis.Descriptive statistics such as percentages and frequencies were used to summarize the data.The informant consensus (ICF) factor was conducted to determine the homogeneity of the medicinal plants' information collected from the respondents using formula 1 [11]: where "Nur" refers to the total number of use reports (URs) for each condition cluster and "Nt" refers to the total number of species in each use category.The ICF values range from 0 to 1. High ICF values (close to 1) are obtained when only a few plant species are reported to be used by a high proportion of informants to treat a particular disease and this implies that there is a well-defined mechanism in the community of sharing information between informants.When a variety of plant species are utilized to treat the same condition, individuals prefer one over the other.Therefore, preference ranking was performed to determine which species were preferred over others as described in Martin [11,12].Key informants were tasked to compare the given botanical remedies based on their values.The most preferred plant species were ranked highest on a scale of 1-5, 5 being the most preferred and 1 being the least preferred.

Paired comparison of medicinal plants used to manage postpartum bleeding induce uterine contraction and abortion
A paired comparison was made for the five most potent medicinal plants used for the aforementioned conditions in the study area.Following the focus groups, participants were requested to rank the species based on their efficacy in the management of maternal health conditions as follows: 1 = least, 2 = good, 3 = very good, and 4 = excellent [11].

Demographic characteristics of the respondents
The socio-demographic characteristics of the study population are shown in Table 1.Two hundred six respondents were interviewed (87.4% female and 12.6% male) on the plants they used to induce uterine contractions, treat postpartum bleeding, and induce abortion.Most of the respondents had attained primary education (51.5%), were Roman Catholic (34.5%), married (70.4%), and 47.4% were business persons.The majority of the respondents were from Nsakya (78.6%) parish and Nsakya A (22.8%), Nsakya B (24.3%), and Mubango (14.6%) villages.Nsakya parish had the highest population thus more villages were sampled as other parishes had very few scattered households.Traditional birth attendants reported not to have lost anyone while helping them to give birth.81% of the respondents reported that they used plants for treating PPH.83% reported using plants for uterine contractions and 65% reported using plants for abortion.The majority (75%) of the respondents reported using uterotonic plants as a single plant, not in combination.Once the uterus failed to contract, 44.2% of respondents used conventional drugs (Fig. 2).Relatives (34.3%) were the major sources of knowledge regarding the use of uterotonic plants followed by parents (29.5%) and friends (21%) (Fig. 3).Among the relatives, grandmothers (75.3%) provided the majority of the indigenous knowledge and among the parents, mothers (96.3%) provided the majority of the indigenous knowledge.
34% of uterotonic plants were collected from the forest followed by 31% from the garden (Fig. 4).The majority of the respondents reported that uterotonic plants were very effective (62.1%) followed by those who said they were effective (37%) and only 1% reported that the plants were not effective at all.The majority of the respondents stored their botanical remedies using traditional storage methods (Fig. 5) but 37% did not store them because they believed they were readily available and could easily be picked from the forest when the need arises.
Whereas some herbal remedies can have tremendous side effects especially uterotonics which can cause uterine rupture and death, 73% of the respondents reported not experiencing any challenges while using uterotonic herbal remedies.

During focus group discussions, women were asked about the challenges they experienced while using hospital uterotonics. Their responses were; Hospital uterotonics cause dizziness coupled with headaches; they are very expensive; health centers are very far away; inexperienced intern doctors administer uterotonics before delivery time thus causing the child to kill the mother when they kick the heart; they cause hypertension, nausea, pelvic pain, pyrexia, naval and spinal pain, vomiting; sometimes they are very ineffective.
49% of the respondents grew uterotonic plants.The most commonly grown uterotonic species included; C.Those who did not grow plants reported that they were available in the forest (81.3%) followed by those who said some species would not grow when taken out of the forest (8.1%), those who reported that some species grow on their own were (8.1%) and 2.4% said there is no market for the plants thus no need to grow them.Additionally, 88.8% of the respondents did not buy uterotonic plants from the market.This is majorly because they are available from the wild (forest, bushes, grazing land) (55.2%).Those who went to the market purchased the A. mauritianum roots, C. gynandra roots, C. papaya roots mixed with mud and clay, A. esculentus fruits, W. ugandensis stembark, C. adenocaule leaves, E. abyssinica leaves, P. barbartus leaves, H. opposita leaves, P. prostratus leaves.
During focus group discussions, women were asked why they preferred Traditional Birth Attendants to hospitals.The responses were; TBAs are polite and give a lot of care to expectant mothers; they provide herbs to induce labour; are nearby and cheap; are very knowledgeable and experienced; provide simple requirements for delivery; give free food; TBAs always do a follow-up and provide post-partum care; they give loans and you pay after delivery; they give enough time to mothers and have emergency deliveries; TBAs help mothers suffering from HIV who are stigmatized from hospitals thus fearing to go there.
Despite the love and trust for TBAs by mothers, 14.1% reported having lost their relatives and children in the hands of TBAs during delivery.
When asked why mothers did not like going to hospitals for delivery their responses were; Hospitals are very expensive and very far; midwives are rude and in most cases beat up mothers, women don't like taking medication, especially antimalarials e.g.fancida, arm injections e.g.tetanus shots; some women can not afford hospital requirements e.g.disposable plastic bed cover, mama kit (contains plastic sheeting, razor blades, cotton wool, gauze pad, soap, surgical gloves, exam gloves, cord ties, and a child health card), hospitals are expensive; fear to test for HIV; intern doctors make mothers push the baby before labor pains which always ends up in killing the mother and baby; poor c-sections  The species used for postpartum hemorrhage, uterine contraction, and abortion belonged to 49 families and 104 genera (Table 2).The majority of the species belonged to the family Lamiaceae (16.3%) followed by Fabaceae (14.3%).Hoslundia opposita was the most frequently used species with 109 mentions.The high frequency arises from its use for treating postpartum hemorrhage, cleansing the uterus after birth, healing vaginal tears and stiches after birth, and is thus considered extremely effective by most mothers.In addition to the diversity of plant species used in maternal care by the women in Najjembe sub-county, none plant materials (snail shells, egg shells, cow dung, and snakeskin) for inducing uterine contractions, and Medusomyces gisevii L. mushroom was also used for treating postpartum hemorrhage (Table 3).According to preference ranking, Aloe vera was most preferred followed by Capsicum frutescens (Table 4).
From the pairwise ranking of the five most effective plants, Hoslundia opposita was the best with a score of 42. (Table 5).Most species used in the herbal preparations grew as herbs (40%), followed by trees (21.9%) and shrubs (16.2%).(Fig. 6).The majority of the herbal preparations were made using leaves (51.2%) followed by roots (17.3%) and stembark (10.2%) (Fig. 7).Majority of the herbal preparations were prepared by decoction (37.7%) followed by those they squeezed in water (28.5%) (Fig. 8).They were then administered orally (72%) followed by topically (14.4%) and through the vagina (10.6%) (Fig. 9).Despite the significant contribution of the plant species in Table 2 to women's reproductive healthcare, a number of side effects (Table 6) were reported by the mothers on excess consumption of these herbs or on the consumption of the herbs before labour contractions commenced.

Discussion
The process of giving birth brings joy to the family but prenatal and postnatal care is key to the survival and health of the mother and baby.Thus, this study highlights the significant contribution of indigenous plant species to the reproductive health of women in marginalized communities and more so in low-income countries.It goes further to point out the deleterious side effects of some of these species upon consumption in excess amounts or on consumption before labour pains commence.
Additionally, non-plant materials (egg shells, cow dung, snakeskin, and mushroom -Medusomyces gisevii ) were also reported to have oxytocic properties.Medicinal plants used for labour induction were used from seven months until the end of the gestation period (normally 9 months) or at the onset of labour pains.Plants that induce uterine contractions have similar action as that of oxytocin hormone, produced on the posterior lobule of the hypophysis, which stimulates the uterus and causes strong contractions, thus inducing labour [13].Since  uterine atony is the major cause of postpartum bleeding [14], plants that induce labour in addition to inducing or augmenting labor are also used in the treatment of postpartum hemorrhage [15].Post-partum hemorrhage is the leading single direct cause of maternal mortality worldwide [16].Thus the doubled role played by these plant species emphasizes the importance of documenting and conserving them.Abortion is considered a sin according to religious teachings but is also considered an abomination in the majority of African cultures.Nonetheless, legal abortions are accepted on the grounds that there is a risk to the life or health of the pregnant woman if the pregnancy results from rape, incest or sexual violence, severe or fatal fetal anomaly, or socio-economic grounds.However, these grounds can be expressed in legal texts in 'vague and confusing' ways, making them even more difficult to implement [17].Furthermore, several United Nations human rights bodies have recognized the deleterious impact of restrictive abortion laws on women's health [18][19][20] and have consistently raised general concerns about the inaccessibility of safe abortion services.Results of this study showed that the majority of the women's reasons for abortion were domestic violence and neglect from the spouses-to-be.This shows a gap in the social support especially councilling services at the village level.The respondents also noted that some uterotonic plants could serve as abortifacients for the case of Hoslundia opposita, Senecio discifolius, and Cucurbita pepo.
The famous "Emumbwa" is another traditional medicine you can not miss to find in every pregnant woman's home."Emumbwa" is a mixture of different herbs and clay which form a bar when dry.The clay in "emumbwa" is believed to contain minerals like iron and calcium, and this bar preserves the herbs mixed into it and thus can be stored for over a year without going bad.Many pregnant women in Uganda drink this clay and herb concoction to manage morning sickness, treat illnesses including malaria, syphilis, candida, and induce uterine contractions.Some believe the herbs can alter the sex of a child and cleanse them from curses.Women get "emumbwa" from TBAs though the majority buy them from herbalists, and herbal medicine vendors, who live in towns and cities [7].
Uterotonic plants have stood the test of time among locals but the childbirth process can not rely on the use of plants alone as women may have several diseases and complications that require modern hospitals.Additionally, some women may not know the correct month to start taking oxytocic plants thus they can end up taking them during the early months of pregnancy thereby inducing an abortion [13].Whereas TBAs are highly  trusted by the village women, the majority of the TBAs are very old women living in small dirty huts and with poor eyesight.This puts at risk the survival of the mother and the unborn child.On that note, women noted the major cause of death during childbirth in Najjembe is PPH due to uterine atony and this usually occurs at TBAs.Giving birth at TBAs and at home increases the vulnerability of poor, rural women to post-partum hemorrhage [21].Some plant species documented in this study were found to be used elsewhere in Uganda and other countries.For example, the women in Najjembe chewed the raw roots of Cleome gynandra to induce labour.According to Oryem et al. [22], Cleome gynandra is widely used in hastening childbirth.A herbal drug made up of Cleome gynandra is used widely to fasten childbirth [23].Cleome gynandra roots are chewed in Western Uganda to induce labour [6].
The methanolic extract of Bidens pilosa has been reported to show weak uterine stimulant effects on the guinea pig uterus in Rwanda [24].Women in western Uganda smoke B. pilosa in a pipe or drink the water extract to induce labour [6].Bidens pilosa aqueous and methanolic extracts increase uterine motility and strongly augment oxytocin activity although it has a weak uterine stimulating activity [25].Vernonia amygdalina may indeed contain a potent uterotonic agent, since aqueous extracts (100 mg/mL) induced uterine contraction amplitudes in guinea pig dams that were similar to those of ergometrine [26].Another study showed that the extracts of Commelina africana, Sida corymbosa and Vernonia amygdalina yielded the biggest increases in contractility in the uterine model, i.e., 31.8% at 210 min, 32.8% at 210 min, and 28.3% at 150 min, respectively [27] and maintained the contractile effect for 2.5-3.5 h, suggesting an added benefit in terms of being long-acting and having a sustained uterotonic action.Vernonia amygdalina roots are chewed to induce labour [6].Vernonia amygdalina and Ocimum gratissimum are regularly consumed as soup during pregnancy to promote easy progression, strengthen or tone the uterus muscle, and prevent complications, such as pain, bleeding, and abortion [28].However, during labor, these two plants are administered fresh as squeezed leaves or aqueous extracts same as the women in this study.
Carica papaya latex induces spasmodic (tetanic spasms) contraction of the uterus muscle, similar to oxytocin and prostaglandin F2α [29], and the roots are chewed to induce labour [6] which is in agreement with this study.Commelina erecta is inserted in the vagina to induce labour [6].The majority of the women in Najjemebe reported that the sap was very potent for abortion as it opened up the cervix within one hour.Nonetheless, due to the high potency, many women die in the process due to over-bleeding and strong pains.Luffa cylindrica Once used and fails to work it leads to death 13 Ficus natalensis Hochst.
Too much before labour pains, you get wounds in the uterus 15 Indigofera arrecta Hochst.ex A.Rich.
Too much leads to leaking of the amniotic fluid 16 Markhamia lutea (Benth.)K.Schum.
Too much can lead to loss of blood while giving birth 17 Prunus africana (Hook.f.) Kalkman.Death 18 Cardiospermum halicacabum L.
Excessive bleeding aqueous leaf extract ruptures uterine membranes thereby causing strong (oxytocic) uterine contractions that are immediate and stable for more than 30 min thereby speeding up labour during childbirth [30].Whereas some plant species have been reported by other authors as inducers of uterine contractions, in this study they played a double role in inducing labour and treating postpartum hemorrhage.Diterpenes, phenylpropanoid glucosides, heterocyclic aldehydes, fatty acids, saponins, sterols, and polypeptides have been reported to be responsible for the uterotonic activity of the oxytocic plants [27].
The high maternal mortality rate in Uganda and other low-income countries means many of these women did not receive the necessary maternal care due to socioeconomic factors [21], but they have access to medicinal plants, which potentially could save them [31].Therefore, documentation and biological identification of traditionally used herbal remedies is an ideal starting point for biological target-oriented drug discovery efforts and their pharmacological characterization may eventually lead to the development of novel uterotonic drugs thereby improving the reproductive health of women with low access to primary healthcare [27].

Conclusion
This study presents a high diversity of plant species embedded in the indigenous healthcare system of women living in Najjembe sub-county, Buikwe district, Uganda.The continuous and trusted use of plants by women, herbalists, and traditional birth attendants in inducing labour, abortion, and treating postpartum hemorrhage is an indicator that these herbs are potent and could guide the discovery of novel oxytocics.Additionally, the deleterious side effects caused by overconsumption and consumption of these species before labour pains commence have also been reported.Thus, a need for field and laboratory research to establish the appropriate dosage, toxicity, and efficacy levels to address the current crisis and mysteries surrounding maternal and infant mortality in Uganda [6].Abortifacient plants with their harmful effects have not yet been studied thoroughly thus the a need for a thorough examination of their plant extracts to test them for potential toxicity and mutagenicity [15].Scientific investigations on plants that contribute to maternal health of marginalised populations can guide the formation of informed health policies, guide safe motherhood programmes, as well as collaborative approaches involving training traditional birth attendants thereby equipping them further.This study also noted the need to set up counseling services for adolescents and mothers as the most noted causes of abortion were failed relations and domestic violence.

Fig. 1
Fig. 1 Map of study location showing Najjembe sub-county in Buikwe district

Fig. 3 Fig. 2
Fig. 3 Sources of indigenous knowledge on medicinal plants used by women in Najjembe sub-county, Buikwe district

Fig. 5 Fig. 4 Table 2
Fig. 5 Storage methods for herbal remedies used by women in Najjembe sub-county, Buikwe district

Table 5 Fig. 6
Fig. 6 Habits of plants used by the women in Najjembe subcounty, Buikwe district

Fig. 9
Fig. 9 Methods of administration for botanical remedies used by women in Najjembe sub-county, Buikwe district

Fig. 8 Fig. 7
Fig. 8 Plant parts used in the preparation of botanical remedies by women in Najjembe sub-county, Buikwe district

Table 1
Demographic characteristics of the respondents

Table 3
None plant materials used for treating postpartum hemorrhage and inducing uterine contractions

Table 4
Preference ranking of medicinal plants used by the women in Najjembe sub-county, Buikwe district

Table 6
Side effects caused by some of the plant species used for treating postpartum hemorrhage, inducing uterine contractions, and abortion by the women in Najjembe sub-county, Buikwe Carica papaya L.The uterus can fail to open leading to death 11 Musa paradisiaca L.